Cellulite: a review of pathogenesis-directed therapy
Daniel J Callaghan III, MD;1 Deanne Mraz Robinson, MD;2 and Michael S Kaminer, MD3
■ Abstract
Cellulite is a condition that affects the majority of postpu-
bertal women and can negatively impact quality of life.
This review discusses several proposed pathophysiologies
of cellulite, and examines treatment options that have
been utilized, focusing on the etiologic factor targeted
by the therapies. This approach aims to help clarify the
pathogenesis of cellulite and provide a road map for de-
veloping effective treatment paradigms for patients.
Semin Cutan Med Surg 36:179-184 © 2017 Frontline
Medical Communications
C
ellulite represents the dimpled or orange-peel appear-
ance of the skin’s surface most commonly found on the
posterolateral thighs, buttocks, and abdomen of women.
Many women view cellulite negatively as an imperfection, and
may not be aware that it affects women of all shapes, sizes, and
backgrounds. Although there is no precise epidemiological data
on the prevalence of cellulite, it is thought to affect 80%-90% of
postpubertal women.1
Despite being a common, physiologic occurrence in women, it
cannot be overlooked that cellulite is considered undesirable, and
can even cause considerable distress to those affected by it. The
distaste for cellulite was reportedly started in the United States
with the 1968 cover article of Vogue magazine titled, “Cellulite,
the New Word for Fat You Couldn’t Lose Before.”2 This villain-
ization of cellulite has only been made worse as women compare
themselves to the ‘ideal’ standards portrayed in mass media, over-
looking the truth that these images often depict altered, unrealistic,
and unattainable perfection. Furthermore, the explosion of social
media has been linked to increased body dissatisfaction due to self-
objectification, appearance comparison, and internalization of un-
realistic ideals.3
Although the negative opinion towards cellulite may simply be a
product of our society, it is important for the clinician to recognize
that it does pose a serious concern for those affected. One study
reported that it caused a negative impact on the quality of life of
84.6% of participants, with nearly one-third indicating that cel-
lulite had a moderate to severe impact on their quality of life.4 An-
1
Boston Medical Center, Boston, Massachusetts.
2
Connecticut Dermatology Group, Milford, Connecticut.
3
Skincare Physicians, Chestnut Hill, Massachusetts.
Disclosures: Dr Callaghan has nothing to disclose. Dr Robinson has done
research, is on the speakers bureau, and served on advisory boards for Merz/
Ulthera. Dr. Kaminer reports personal fees from Merz, outside the submitted
work.
Correspondence: Daniel J Callaghan III, MD; DanielJCallaghan3@gmail.com
1085-5629/13$-see front matter © 2017 Frontline Medical Communications
https://doi.org/10.12788/j.sder.2017.031
V36i4 Callaghan.indd 179
other observational study found that 70% of patients being treated
for cellulite felt that their cellulite hampered their lives ‘greatly.’5
Therefore, even though cellulite is not considered a disease, a
“cure” has long been sought by patients and clinicians alike. This
review discusses the proposed pathophysiology of cellulite and ex-
amines treatment options that have been utilized, focusing on each
etiologic factor the therapies have targeted. By critically evaluating
treatment options, we aim to provide a road map for developing
effective treatment paradigms for patients.
Etiology
As patients may mistakenly use the terms ‘fat,’ ‘adipose,’ and ‘cel-
lulite’ interchangeably, it is important to understand the differences.
Adipose tissue, also known as body fat, is a type of connective tissue
made up of adipocytes, collagen, blood vessels, and nerves. There
are 2 main reservoirs for fat tissue in the body: visceral fat and sub-
cutaneous fat. Unlike visceral fat, subcutaneous fat is not thought to
contribute to obesity-related metabolic and cardiovascular diseases,
and may even be protective.6 Though cellulite is made up in part by
subcutaneous fat, cellulite describes the topographic dimpling and
nodularity of the skin resulting from underlying adipose tissue her-
niating through subcutaneous fibrous connective tissue.
To better understand this relationship, it is worthwhile to exam-
ine the anatomical structure of subcutaneous tissue. Subcutaneous
tissue is made up of 2 layers of fat, referred to as the superficial and
deep layers. These are separated by the superficial fascia, which is
a sheet of connective tissue primarily made up of collagen. Some
confusion exists regarding how many layers of fat make up the
subcutaneous tissue, as some authors reference 2 layers while oth-
ers reference 3.7–11 This inconsistency may be a byproduct of the
structure of the superficial fascia, which is composed of a variable
number of layers depending on the location of the body being ex-
amined. These layers in turn can have fat deposited within them.12
For example, in the abdomen the superficial fascia is composed of
a fatty outer layer, more commonly known as Camper’s fascia, and
a more membranous deep layer, known as Scarp’s fascia. Camper’s
fascia is continuous with the superficial fascia of the thigh while
Scarpa’s fascia does not extend past the inguinal ligament. With
this anatomic relationship in mind, for the purposes of the discus-
sion on cellulite, there are 2 clinically relevant layers of subcutane-
ous fat: one above the superficial fascia and one below.
In women, the superficial adipose layer is made up of larger fat-
cell chambers compared to men. These fat-cell chambers can proj-
ect upwards into the dermis, changing the overall appearance of
skin.7 Fibrous bands of collagen course through the subcutaneous
fat from the undersurface of the dermis to the deep fascia adja-
cent to muscle. In men, these bands run in a crisscrossing fashion;
while in women, they are more frequently oriented perpendicularly
(Figure 1).7 As such, the subcuticular fat in men is separated into
Vol 36, December 2017, Seminars in Cutaneous Medicine and Surgery 179
11/21/17 4:14 PM
 ■ ■ ■ Cellulite: a review of pathogenesis-directed therapy
■ FIGURE 1. Representation of the sex-typical differences of the
orientation of fibrous septae in the subcutaneous tissue.
Illustration: Designua/Shutterstock.com
smaller, polygonal units allowing for tension to be evenly distrib-
uted throughout the skin and subcutaneous tissue. Conversely, the
perpendicularly oriented septae in women create localized points
of tension, acting to tether the dermis to the subcutaneous tissue.
This alters the dermal-subcutaneous interface and creates the roll-
ing, dimpled appearance that is the hallmark of cellulite (Figure
2).7 The sexual dichotomy of fibrous septae and the resulting role
they play in the appearance of cellulite has been demonstrated with
magnetic resonance imaging.9
The difference in orientation between the fibrous septae in males
and females is seen as early as the third trimester of pregnancy,7
making it clear that there are other forces involved in the develop-
ment of cellulite. Although the specific elements that contribute to
the formation of cellulite have been a matter of debate for years,
it is now thought that cellulite is caused by a complex interplay of
several factors. These include persistent low-grade inflammation,
microvascular dysfunction and tissue edema, localized adipocyte
hypertrophy, collagen denaturation, tissue laxity, and connective
tissue fibrosclerosis.13,14
Given the debate over the pathogenesis of cellulite, throughout
the years, a number of starkly different treatment options have
been developed and trialed with limited success. Fortunately, as
our understanding of its pathogenesis has improved, so too has our
ability to treat cellulite, and recently several treatment modalities
have shown promise where so many others previously produced
lackluster results.
Treatment
Prior to treating any patient for cellulite, it is important to do a
thorough pretreatment assessment and to clearly set goals and ex-
pectations. It is crucial to understand what the patient perceives
to be cellulite, as some may consider it to be any excess bulge of
adipose tissue or area with tissue laxity. Treatment of cellulite, skin
laxity, and body contouring are not one and the same.
After identifying the specific pathology for which the patient
is seeking treatment, the clinician must outline the different treat-
ment options available. As will be highlighted below, not all treat-
ment options are equivalent in terms of improving cellulite. Many
180 Seminars in Cutaneous Medicine and Surgery, Vol 36, December 2017
V36i4 Callaghan.indd 180
■ FIGURE 2. The relationship between fibrous septae, which are
tethered from the dermis to the subcutaneous tissue, and the re-
sulting dimpling of the skin.
Illustration: Adapted from Alila Medical Media/Shutterstock.com
available treatment options, even those that are approved by the US
Food and Drug Administration, do not provide sustainable or long-
lasting results. Additionally, there is often heterogeneity in terms
of what the treatment regimen requires of the patient, with some
requiring only a single office visit while others require followup
at weekly or monthly intervals for a considerable length of time.
Finally, the patient should be evaluated and photographed in a
standardized manner with appropriate lighting, so that post-treat-
ment progress can be easily monitored. Depending on the expec-
tations previously established, the ability to compare results to
pretreatment images can lead to more content patients.
There are several classification systems for the grading of cel-
lulite that can be used in this pretreatment assessment. A widely
utilized tool for cellulite evaluation is the cellulite severity scale
(CSS) proposed in 2009 by Hexsel and colleagues. The CSS evalu-
ates 5 clinical features of cellulite including (1) number of evident
depressions; (2) depth of depressions; (3) morphological appear-
ance of the skin surface alterations; (4) grade of laxity, flaccidity
or sagging skin; and (5) the previously proposed Nürnberger and
Müller scale. Each feature is graded on a scale from 0 to 3, and the
sum is added to provide a grade of mild (1-5), moderate (6-10) or
severe (11-15).15 The complexity of the CSS allows it to account
for the many different clinical and morphological features of cel-
lulite that influence its severity. Such an objective, uniform, and
reproducible grading system is useful not only in clinical practice,
but also when assessing new or established management strategies.
Although the completeness of the CSS is in some ways beneficial,
the absence of a simplified grading scale for cellulite can lead to
challenges in discussing treatment options and efficacy. This re-
mains a subject of ongoing investigation.
In terms of treatment options, a diverse array of techniques has
been trialed in the past with varying degrees of success. Although
many past studies have reported an improvement in cellulite with
the investigated intervention, it is important to note that many of
the studies are lacking in academic rigor. That is, many studies
published on the treatment of cellulite suffer from flaws such as
small sample sizes, lack of reporting of statistical significance, lack
11/21/17 4:15 PM

of a control group or randomization, or are nonblinded. Further-
more, some studies have relied on a wide variety of endpoints that
have been subjective, inconsistent, fail to measure a valid indicator
of cellulite severity, or lack extended follow-up. Studies that report
improvement at 1- or 6-month intervals are clinically limited if
they are unable to demonstrate a sustained response.
These limitations are echoed in 2 recent systematic reviews on the
treatment of cellulite that included 73 and 67 studies, respectively,
and found no clear evidence for an effective treatment option for
cellulite.16,17 Although this highlights the difficulties that have been
encountered in past attempts to treat cellulite, several new treatment
options with encouraging results have been established.
Given the wide array of treatment options available, this review
will group strategies based on the etiologic factor of cellulite being
targeted. Although many of the treatment options may be targeting
more than one target, an attempt will be made to highlight the chief
target for each, including the following: microvascular dysfunction/
tissue edema, excess adipose tissue, collagen thinning/denaturation
and tissue laxity, and thickened fibrous septae. Additionally, there
are several devices that exist which combine several different treat-
ment modalities that will be subsequently discussed as well.
Microvascular dysfunction and tissue edema
Cellulite has been viewed as a type of localized edema resulting
from alterations in vascular and lymphatic microcirculation.18,19
With that in mind, a number of treatment options have been devel-
oped aimed to improve circulation and reduce tissue edema.
Methylxanthines, such as caffeine, have been used in a variety
of topical formulations in isolation as well as combined with other
ingredients such as retinols or botanical derivatives. Caffeine has
been hypothesized to improve cellulite, not only by improving vas-
cular and lymphatic flow, but also by direct lipolysis.20 Two stud-
ies found that topical formulations of caffeine of varying strengths
had statistically significant reductions in mean thigh circumference
from baseline at 1 and 2 months;21,22 however, posttreatment fol-
lowup was not considered.
Mechanical stimulation has been used to target cellulite manu-
ally or with the use of a device such as the handheld skin-knead-
ing device Endermologie (LPG Systems, Valence, France). This
method aims to reduce cellulite by stimulating microcirculation as
well as improving lymphatic drainage.23 Treatment is burdensome,
with studies sometimes requiring more than 10 sessions over the
course of several weeks, each lasting up to 1.5 hours. Although
studies have reported reduced thigh circumferences after treatment
with mechanical stimulation, they did not use placebo or untreated
controls, and long-term followup has not been published despite
the fact that it is one of the oldest treatment options available.23-25
Acoustic wave therapy, or extracorporeal shock-wave therapy,
utilizes energy waves to deliver localized pulses with the goal of
improving local blood circulation and reduce lymphedema.26,27 A
recent meta-analysis of 11 studies, including 5 randomized-con-
trolled trials, does suggest acoustic wave therapy is effective in im-
proving cellulite.28 Despite the attractive results, the sustainability
of this therapy has been questioned as none of the studies followed
patients past 6 months, and only 1 out of the 11 studies had follow-
up longer than 3 months. Furthermore, this technique requires mul-
tiple sessions over the course of several weeks or months which
makes it less practical for some patients.
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V36i4 Callaghan.indd 181
Callaghan et al
Altered subcutaneous adipose tissue
In general, there is still a perception by many that cellulite is pri-
marily a disease of excess adipose tissue, despite the fact that even
women with a normal body mass index (BMI) develop cellulite.10
That being said, a higher BMI has been associated with more se-
vere cellulite, therefore adipose tissue has been targeted as a thera-
peutic technique.8
Weight loss is often suggested to patients as a way to manage
cellulite. Smalls et al demonstrated that for the majority of patients,
medically supervised weight loss can improve the severity of cel-
lulite as measured by surface roughness parameters. However, they
alternatively found that in a subgroup of patients, weight loss led
to worsening of cellulite.29 They proposed that this subgroup ex-
perienced paradoxical worsening due to an increase in skin laxity
without a proportional change in subcutaneous fat. They also con-
cluded the “dimpled pattern” of cellulite to be a permanent struc-
tural change that cannot be affected by weight loss.
Cryolipolysis has been utilized to treat cellulite stemming from
the observation that adipocytes are selectively sensitive to cold in-
jury relative to surrounding tissue, and thus can be targeted with
the goal of adipolysis.30 This hypothesis does appear to have some
merit, as cryolipolysis has been shown to produce reliable decreas-
es in subcutaneous tissue deposits in the setting of body contour-
ing.31,32 Additionally, cryolipolysis has been demonstrated to cause
tightening of the skin, potentially as a result of neocollagenesis.33
Despite these benefits, the architectural complexity of cellulite pre-
vents the generalization of these results. For this reason, a review
on noninvasive body contouring devices, including 22 specifically
looking at cryolipolysis, found that while it is an effective tech-
nique for the treatment of unwanted fat bulges, it is not a definitive
treatment for cellulite.30 Furthermore, long-term evidence in these
studies is lacking.
As opposed to acoustic wave therapy, ultrasound or high inten-
sity focused ultrasound (HIFU) uses molecular vibration to deliver
energy and cause coagulative necrosis of fat cells while sparing
surrounding tissues.34,35 Similar to cryolipolysis devices, HIFU ap-
pears to be safe and efficient for decreasing localized subcutane-
ous adipose tissue as measured by waist circumference. However,
there is no strong evidence that it is a reliable treatment option for
the management of cellulite given the accompanying architectural
changes that are involved.30,35,36
Low-level laser therapy, as opposed to the more frequently used
high-energy lasers, does not heat tissue, but rather is thought to
cause adipolysis by breaking down lipids in adipocytes which
leads to the formation of pores in their cell membranes.37 Several
studies looking at low level lasers with wavelengths varying from
532 nm, 635 nm, and 808 nm, have shown inconsistent results for
the treatment of cellulite, and were limited by small sample sizes,
and limited follow-up.17,30,36
High-powered lasers, such as the 1064 nm Nd:YAG laser, have
been used in the treatment of cellulite to selectively target and
disintegrate adipocyte membranes and also cause skin tighten-
ing.38,39 Two open-labeled randomized studies involving a total of
31 subjects treated with the 1064 nm Nd:YAG laser did not observe
significant improvement in cellulite severity, although Bousquet-
Rouaud et al reported improvement in dermal density.40,41 Overall
there is little evidence that this noninvasive device is effective in
treating cellulite.
11/21/17 4:15 PM
 ■ ■ ■ Cellulite: a review of pathogenesis-directed therapy
A B
■ FIGURE 3. Magnetic resonance images of the same area
treated with subcision. A) Baseline: arrow 3 shows a single fibrous
septa creating a depression which is marked by a capsule, and
B) the same area showing the severed septa 7 months after sub-
cision. The arrows 1 and 2 indicate anatomic structures used as
a guide to obtain the same slices. Reused with permission from
Hexsel D, Dal Forno T, Hexsel C, et al. Magnetic resonance imaging
of cellulite depressed lesions successfully treated by subcision.
Dermatol Surg. 2016;42(5):693-696.48
Collagen denaturation and tissue laxity
Cellulite has also been postulated to be the result of weakened col-
lagen and tissue laxity, resulting in protrusion of adipose pockets and
the dimpled appearance of skin. For this reason, other treatment de-
vices have been aimed at thickening collagen and tightening tissue.
Radiofrequency (RF) devices are used to transmit energy in the
form of an electrical current to the dermis and subcutaneous tissue,
causing collagen denaturation and subsequent neocollagenesis and
tissue tightening.42 RF devices are available as unipolar, bipolar,
and more recently tripolar devices. Unipolar devices disperse en-
ergy throughout tissue, potentially making them more difficult to
control. Bipolar and tripolar devices use 2 and 3 electrodes, re-
spectively, which theoretically allows for localized control as the
current runs between the electrodes.43 A review of 16 studies evalu-
ating RF in the treatment of cellulite found no strong evidence in
its support, because either no valid statistical analyses were pro-
vided or results did not reach statistical significance.17 An excep-
tion was one subject-blinded randomized control trial by Mlosek et
al which found a statistically significant improvement in cellulite
treated with the tripolar RF device T1 (Beauty Light Science and
Technology Co, Ltd, Beijing, China) compared to a sham device.44
A short follow-up period of 4 weeks limits the generalizability of
the results of this trial.
Infrared light has been shown to increase collagen synthesis
while simultaneously improving microcirculation and lymphatic
drainage.45 With this in mind, several studies have evaluated in-
frared light’s ability to improve cellulite. Paolillo et al reported a
statistically significant improvement in saddlebag and thigh cir-
cumference after 3 months of twice weekly treatment with an 850
nm infrared device combined with treadmill training, but no objec-
tive improvement in cellulite was reported.45 Bagatin et al reported
no discernable difference when comparing a treatment group ex-
posed to long-wave infrared radiation to the untreated control.46 In
general, these devices do not appear to offer encouraging results
for the management of cellulite.
Fibrous septae
Another target in the treatment of cellulite are the fibrous septae
that tether the skin to subcutaneous tissue, which have been pro-
182 Seminars in Cutaneous Medicine and Surgery, Vol 36, December 2017
V36i4 Callaghan.indd 182
posed to lead to the dimpled appearance of cellulite.9,47 Magnetic
resonance imaging has been used to demonstrate the association
between fibrous septae and clinically evident depressions, which
show resolution after treatment (Figure 3).48
The simplest way to treat these fibrous septae is with manual
subcision, in which individual septae are dissected with a needle
or blade. A retrospective observational study by Hexsel et al in-
volving 232 patients treated with subcision found that 78.87% of
patients were satisfied with their improvement and an additional
20.25% were partially satisfied.47 The study was limited by the fact
that it did not have a control and results were subjective. However,
it did report a longer followup period than most other studies in-
volving cellulite, and 23 (9.91%) patients who were followed for
more than 2 years maintained improvement. Posttreatment adverse
events included bruising seen in all patients, which subsequently
developed into dyspigmentation lasting up to 10 months as a result
of hemosiderosis. In 90% of patients, this bruising was associated
with tenderness for up to 4 months. Moreover, 3% of patients even-
tually developed persistent erythema.
Though manual subcision provided encouraging results, the pro-
cedure is limited by operator technique. In an effort to expand and
improve upon the use of subdermal undermining to treat cellulite,
a device aimed at automating the process was developed. Cellfina
(Ulthera/Merz, Mesa, Arizona) is a device that utilizes vacuum-as-
sisted tissue guidance to administer anesthesia and release fibrous
septae. Kaminer et al studied 55 women who underwent a single
treatment and found that at 1 year, 94% of subjects had improve-
ment of 1 grade or more as evaluated by blinded observers using
an objective, validated Cellulite Severity Scale (CSS).49 The mean
change in CSS at 1 year was 2 points (P < .0001). In contrast to the
majority of other studies published on the treatment of cellulite,
the subjects were followed over time, and at 3 years posttreatment,
91.1% of subjects had sustained improvement as determined by
the same objective CSS. Patient satisfaction reached 96% and 93%
at 2 years and 3 years posttreatment, respectively.50 Given these
results, vacuum-assisted subcision devices may provide an accept-
able, reproducible, and durable treatment option for cellulite with
high patient satisfaction. In light of this data, the US Food and
Drug Administration has cleared Cellfina for the treatment of cel-
lulite for results that last up to 3 years, the longest duration of any
device cleared by the FDA.
Alternative to subcision with a needle or blade, Cellulaze (Cyno-
sure, Inc, Westford, Massachusetts) is a millisecond-pulse ranged
1440 nm energy device that is inserted subcutaneously using a can-
nula and thermally subcises septae via a side-firing system. The
laser energy provides the additional benefit of heating the hypo-
dermal adipocytes which results in lipolysis. The energy also dena-
tures adjacent collagen, subsequently stimulating neocollagenesis,
dermal thickening and tissue tightening. As opposed to the laser
devices discussed previously, this minimally invasive device de-
livers the energy internally which allows the subcutaneous tissue
to be targeted more selectively.51-54 In a study of 25 women with
this device, independent assessments showed that 80% of subjects
demonstrated mild improvement at 6 months and 64% of subjects
showing sustained mild improvement at 2 years, although statisti-
cal significance was not reported.51 DiBernardo et al also reported
at least a 1-point improvement in dimple count or contour irregu-
larity in 96% of treated areas at 6 months, which was sustained in
11/21/17 4:15 PM

90% of treated areas at 1 year.52,53 Given this data, the FDA has
cleared Cellulaze for the treatment of cellulite for results that last
up to 9 months.
More recently, Xiaflex (Endo International, Malvern, Pennsyl-
vania), a collagenase produced by Clostridium histolyticum, has
been studied as a technique for the treatment of cellulite. It is a
localized injection that enzymatically degrades the collagen that
forms fibrous septae. A recent Phase 2b study reported that Xiaflex
had statistically significant improvement in the appearance of cel-
lulite as measured by clinician-reported and patient-reported pho-
tonumeric cellulite severity scales (P < .001).55 The study period
was only 28 days and longer-term follow-up is needed to assess if
the benefit is sustainable.
Given these results, it appears that the fibrous septae of cel-
lulite provide clinicians a target that once treated, leads to sus-
tained improvement in the appearance of cellulite. Importantly,
although more invasive than some of the aforementioned treatment
options, these devices are well tolerated with minimal adverse
events.49,51,52,55-58
Combination therapy
There are a number of devices for the management of cellulite that
combine more than one of the above modalities. This multipronged
approach attempts to target more than one etiologic factor of cel-
lulite in order to achieve a more robust response.
TriActive (Cynosure, Westford, MA) combines an 808 nm low-
level light laser, localized cooling, and mechanical manipulation.
SmoothShapes (Cynosure, Westford, MA) combines a 650 nm
LED light, a 915 nm diode laser, and a vacuum-assisted massage
device. VelaSmooth and VelaShape (Syneron Medical, Yokneam
Illit, Israel) combine infrared light, radiofrequency energy, and me-
chanical tissue manipulation. Although there are studies to support
the claim that these devices improve the appearance of cellulite,
they suffer from many of the same limitations previously men-
tioned.16,17 For example, one study evaluating 20 patients treated
with VelaSmooth twice a week for 1 month demonstrated improve-
ment immediately after the completion of treatment, but the results
were not maintained at the 6-month mark.59 In a randomized con-
trolled trial comparing VelaSmooth to TriActive, both devices indi-
vidually were shown to reduce thigh circumference, however there
was no statistically significant difference between the 2 devices.60
Perhaps most telling is the observation that despite these devic-
es having been on the market for many years, there have been no
long-term studies to support their benefit. In part because of the
low level of evidence that exists, 2 recent systematic reviews on
the treatment of cellulite concluded that these combination devices
may not have a beneficial effect on cellulite.16,17
Conclusion
Cellulite is a condition that negatively impacts quality of life, and
therefore has prompted researchers to seek a reliable treatment op-
tion for years. The historical lack of a durable, reproducible so-
lution appears to be reflective of an incomplete understanding of
the pathophysiology of cellulite. Although a number of treatment
options have been trialed over the years, the fact that until recently
none have shown compelling significance or sustainability high-
lights this problem.
Fortunately, several treatment options have recently emerged
Vol 36, December 2017, Seminars in Cutaneous Medicine and Surgery 183
V36i4 Callaghan.indd 183
Callaghan et al
which have shown objective, significant, and durable results. This
enhancement in efficacy, both in terms of quality and duration of
results, can be directly linked to the targeting of fibrous septae,
highlighting the septae’s integral role in the pathogenesis of cel-
lulite. One cannot dismiss the other proposed pathophysiologic
mechanisms of cellulite discussed above; however, it is more likely
that they are ancillary factors, rather than etiologic in their own
regard. With the emergence of treatment options focusing on sub-
cision and the resultant positive impact on fibrous septae, clini-
cians now have cellulite treatment options they can feel confident
recommending to patients.
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